Contact

Company Name

Address1

Address2

City

State

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Zip

County

Company Phone

Company Fax

Email Address

Years in Business

- Choose - New Business Less than 2 Years in Business 2 to 5 Years in Business Over 5 Years in Business

Business Structure

- Choose - Proprietorship Partnership Corporation Limited Liability Corportion

Bank Name

Bank Account #

Avg. Checking Balance

- Choose - Three Figure Low Four Figure Med. Four Figure High Four Figure Low Five Figure Med. Five Figure High Five Figure Six Figure

Avg. Savings Balance

- Choose - Three Figure Low Four Figure Med. Four Figure High Four Figure Low Five Figure Med. Five Figure High Five Figure Six Figure

Principal #1 Name

Title

Home Address

City

State / Province

- Choose - Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming - Canada - Alberta British Columbia Manitoba New Brunswick Newfoundland Northwest Territories Nova Scotia Ontario Prince Edward Island Quebec Saskatchewan Yukon Territory

Zip

Home Phone

Social Security # 

Principal #2 Name

Title

Home Address

City

State / Province

- Choose - Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming - Canada - Alberta British Columbia Manitoba New Brunswick Newfoundland Northwest Territories Nova Scotia Ontario Prince Edward Island Quebec Saskatchewan Yukon Territory

Zip

Home Phone

Social Security #

Equipment Supplier

Salesperson

Equipment Type

Equipment Value

Business Purposes

The undersigned represents that all information provided with this Application is true and correct and hereby authorizes Dick Clark Associates, Inc. to obtain from third parties information Lessor deems necessary to arrive at a decision regarding this Application. Applicant certifies to Dick Clark Associates, Inc. that it is applying for credit for business purposes, and not for personal, family use.

Credit Information Release

The undersigned individual(s), as principal(s) of and/or guarantor(s) for the applicant, recognizing that his or her individual credit history may be a factor in the evaluation of the credit of the applicant, hereby consents to and authorizes the above named business credit provider and any assignee, lender or funding service that may be utilized to obtain and use a consumer credit report on the undersigned, now and from time to time, as may be needed in the credit evaluation and review process. I (we) specifically consent that this information may be transmitted via the internet and waive any right or claim I (we) would otherwise have under Fair Credit Reporting Act in the absence of this continuing consent. Fax, electronic submission, or copy of this authorization valid as original.

Type your full name here:

Date:

By submitting this application I verify that I have read and agreed to the above statements of "Business Purposes" and "Credit Information Release" and that the information provided is true.